Current management of transposition of the great arteries: immediate septostomy, occasional prostaglandin infusion, and early Senning operations

The Southern Thoracic Surgical Association 50th anniversary celebration: the impact of STSA pediatric cardiothoracic surgery manuscripts on surgical practice

BACKGROUND

Members of the Southern Thoracic Surgical Association (STSA) have presented important pediatric cardiothoracic surgery papers at the annual meetings over the last 50 years. In order to determine the influence of these presentations on the practice of surgery, a review was undertaken. Early papers were characterized by emerging advances in open-heart surgery, anatomic congenital heart studies, and electrophysiologic discoveries that extended life with pacemakers. Later years were characterized by innovative myocardial preservation methods, improved cardiopulmonary bypass techniques, expanded homograft availability, emphasis on accurate repairs, intraoperative transesophageal echocardiography, and cardiopulmonary transplantation.

METHODS

All but one of the scientific programs of the annual meetings (that of 1964) were located. The programs were reviewed and 180 presentations were identified on topics in congenital heart disease, pediatric thoracic disease, and pediatric thoracic wall abnormalities. Of those 180 oral presentations, 155 manuscripts (86%) were eventually published or in press and available for critical review and analysis. Manuscripts were grouped by diagnosis or therapeutic intervention. We determined a "cumulative citation frequency" (CCF), which measures the number of times an article is cited in the bibliography of related papers in the universe of participating journals. The selected manuscripts were compared with the historic landmark contributions and the existing trends at the time, and the number of articles both by individual authors and from institutions were tallied.

RESULTS

Grouping by authors and institutions showed that 100 of 155 pediatric cardiothoracic manuscripts (65%) originated from 13 institutions. The CCF for the 20 leading articles ranged from 26 to 93.

CONCLUSIONS

This historical STSA 50-year record of pediatric cardiothoracic advances was accomplished in a milieu of collegial respect and camaraderie. Our annual meetings over the years have provided a venue for thoracic surgeons to share their ideas, innovations, and scientific inquiry. These contributions have significantly affected the practice of pediatric cardiothoracic surgery. The STSA has worked for 50 years and we trust that it will work for another 50 years and beyond.

Role of balloon atrial septostomy before early arterial switch repair of transposition of the great arteries

Preoperative balloon atrial septostomy is the standard therapy for babies with uncomplicated cyanotic dextrotransposition of the great arteries despite the effectiveness of prostaglandin E1 infusion in alleviating systemic hypoxemia and the reported success of arterial switch repair during the 1st weeks after birth. The clinical records and echocardiographic findings of 23 infants (mean birth weight +/- SD 3.3 +/- 0.5 kg) with uncomplicated transposition of the great arteries were analyzed. Fifteen infants (Group I) did not undergo septostomy, and 8 (Group II) underwent septostomy. Before prostaglandin infusion, mean arterial oxygen tension (Po2) in Group I (26 mm Hg) did not differ from that in Group II. After prostaglandin infusion, Po2 increased significantly in Group I (43 +/- 8 mm Hg, p less than 0.001) but not in Group II despite a widely patent ductus and predominant left to right ductal shunt in all. After septostomy, Po2 increased significantly (43 +/- 4 mm Hg, p less than 0.03), and did not differ from that in Group I. Echocardiographic features generally demonstrated a nonrestrictive foramen ovale in Group I and a restrictive foramen ovale in Group II. The latter was associated with persistent hypoxemia after prostaglandin. Thus, the diameter of the foramen ovale was the primary factor influencing arterial oxygenation during prostaglandin infusion. Babies underwent the arterial switch operation at a mean age of 70 +/- 65 h with an overall survival rate of 96%; there was only one postoperative death (Group II). Absence of septostomy had no negative influence on any postoperative variable, including duration of ventilatory and inotropic support, time to discharge, or mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

The Senning operation for complete transposition: mid-term physiologic, electrophysiologic, and functional results

SummaryWe report analysis of surgical results in 110 consecutive infants and children who underwent atrial repair of simple complete transposition using the Senning operation between February 1978 and May 1990. Mean age at operation was 5.4 months ± 6.1 (range 1 week to 4 years); 75 were less than 6 months old. There were 72 males and 38 females. Operative mortality rate was 5.5%, with one late death. Average follow-up is 48.1 months with 44 followed greater than 3 years, and 27 greater than 5 years. Postoperative cardiac catheterization was performed in 48 patients. Right ventricular ejection fraction averaged 0.52 ± 0.08 and was normal in 28 patients. Response of right ventricular ejection fraction to afrerload stress was abnormal in 12 of 14 patients tested. Right ventricular ejection fraction increased normally during exercise in 6 patients, but was abnormal in 15. Mild tricuspid regurgitation was noted in 12 patients. Mild obstruction of the superior caval vein was noted in 4 patients. Baffle leak requiring reoperation occurred in one patient. Fifty-seven of 90 patients are in sinus rhythm by latest electrocardiogram. Postoperative electrophysiologic studies were performed in 34 patients, and Holter monitoring in 25. Significant arrhythmia occurred in 26 patients: 6 patients required pacemakers for slow junctional rhythm or complete heart block; 20 additional patients have a junctional rhythm. Six patients have delayed sinus nodal recovery time. At last follow-up, 88 children (98%) are in New York Heart Association functional Class I, and 2 (2%) are in Class II. The Senning operation for compete transposition can be accomplished with a low operative and late mortality. Serious baffle complications requiring reoperation are rare. Surviving patients are clinically well, but arrhythmias and depressed right ventricular function may limit their long-term functional status.

Ten years' experience with the Senning operation for transposition of the great arteries: physiological results and late follow-up

We report our results in 93 consecutive infants and children who underwent atrial repair of simple transposition of the great arteries using the Senning operation between February 1978 and February 1988. Mean age at operation was 5.6 +/- 6.3 months (range, 1 week to 4 years); 60 were less than 6 months old. There were 65 boys and 28 girls. Operative mortality was 5.4%, and there has been 1 late death. Average follow-up is 45.1 months with 39 followed more than 3 years and 25 followed more than 5 years. Postoperative cardiac catheterization was performed in 43 patients. Right ventricular ejection fraction at rest averaged 0.50 +/- 0.09 and was normal in 26 patients. Response of right ventricular ejection fraction to afterload stress was abnormal in 12 of 14 patients tested. Right ventricular ejection fraction increased normally during exercise in 6 patients, but was abnormal in 15. Mild tricuspid regurgitation was noted in 10 patients. Mild obstruction of the superior vena cava was noted in 4 patients. Baffle leak requiring reoperation occurred in 1 patient. Seventy-two of 80 patients are in sinus rhythm by latest electrocardiogram. Postoperative electrophysiological studies were performed in 34 patients and Holter monitoring was performed in 22. A major arrhythmia occurred in 8 patients: 3 required a pacemaker for junctional rhythm or sinus node dysfunction, 2 have symptomatic or inducible supraventricular tachycardia, 2 have junctional rhythm, and 1 has sick sinus syndrome. Eight additional patients have delayed sinus node recovery time. At last follow-up, 78 children (97.5%) are in New York Heart Association functional class I, and 2 (2.5%) are in class II.(ABSTRACT TRUNCATED AT 250 WORDS)

The Blalock-Hanlon operation: an anachronism?

Some surgeons advocate early correction of dextrotransposition of the great arteries (D-TGA) using hypothermic circulatory arrest when Rashkind balloon atrial septostomy is inadequate. An alternative procedure is a Blalock-Hanlon closed atrial septectomy. From 1971 to 1985, 19 patients underwent the latter procedure for D-TGA at our institution. Three had it as the first procedure, and 16 had undergone Rashkind balloon atrial septostomy, which was unsuccessful. Age at performance of the Blalock-Hanlon closed atrial septectomy ranged from 1 day to 5 months (mean, 2.51 months). There were no operative deaths. Subsequently, 18 children have had a Mustard procedure, and 1, a Rastelli procedure (average age at definitive repair, 25.31 months). One death followed definitive repair (combined mortality, 5%). On room air, average partial pressure of arterial oxygen rose from 23.25 mm Hg prior to closed atrial septectomy to 31.45 mm Hg at discharge. Average hematocrit fell from 58.37% prior to closed atrial septectomy to 53.94% prior to definitive repair. At the time of definitive repair, percentile height ranged from the 3rd to the 95th percentile (mean, 44th percentile) and weight ranged from the 3rd to the 90th percentile (mean, 32.5th percentile). In 1 infant, transient neurological symptoms developed three days following Blalock-Hanlon atrial septectomy. The symptoms were due to multiple cerebral infarctions thought to be caused by emboli. No permanent neurological deficit resulted. We believe that the infant with an inadequate Rashkind balloon atrial septostomy prior to age 6 months should undergo a Blalock-Hanlon septectomy followed by definitive repair timed on the basis of the baby's growth, associated anomalies, and evidence of pulmonary hypertension.

Results with the Mustard operation in simple transposition of the great arteries 1963-1985

From May 1963 to December 1985, 329 infants and children underwent repair of simple transposition of the great arteries (TGA) using Mustard's technique. To assess improvement, the patients were separated into two groups by date of operation: Group I, May 1963 to December 1973 (N = 106), and Group II, January 1974 to December 1985 (N = 223). The operative mortality was 11 (10.4%) in Group I and two (0.9%) in Group II. The 10-year actuarial survival rate was 73.4% in Group I and 93.7% in Group II. Baffle complications, similar in both groups, were identified in 81 patients; 19 were major, causing death or requiring reoperation. By latest electrocardiogram, 21 of 45 (46.7%) of Group I patients and 129 of 180 (71.7%) of Group II patients were in normal sinus rhythm. Late ambulatory electrocardiography, however, revealed that a majority of patients had sinus node dysfunction or other dysrhythmias. Right ventricular (RV) angiography revealed definite diminution of RV contractility in 14 (11%) of 126 children. At late follow-up, 113 of 148 (76%) children were in New York Heart Association (NYHA) Class I and 35 of 148 (24%) were in NYHA Class II. Thirty-five (21%) patients were on cardiac medication chiefly for dysrhythmia management. There has been significant improvement in the early and late mortality with the Mustard operation, and serious baffle complications are infrequent. Dysrhythmias continue to be a major problem but the surviving patients are clinically well and relatively few have significant RV dysfunction.

Late results of the Mustard procedure in transposition of the great arteries

Thirty-five patients were discharged from the hospital after a Mustard procedure and have been followed a mean of 4.5 years. Thirty remain in a stable atrial or sinus rhythm, 3 have required hospitalization and medication to control atrial dysrhythmias, 1 is in a junctional rhythm, and 1 requires a pacemaker. In no patient has there been clinical evidence of systemic or pulmonary venous baffle obstruction. Twenty-two patients have had an elective postoperative cardiac catheterization, which has confirmed the absence of baffle obstruction. We attribute the lack of baffle obstruction and the low incidence of atrial dysrhythmias to several technical points in the operation including: direct high cannulation of the superior vena cava, aggressive resection of the atrial septum except in the region of the atrioventricular node, an extremely large pericardial baffle trimmed in the manner of Brom, sharp divergence of the upper and lower limbs of the inferior suture line away from one another and toward the caval orifices once they enter the right atrium, and very superficial endocardial bites of the baffle suture line in the region of the sinoatrial and atrioventricular nodes.